Periodontal disease is episodic in nature and site specific.

3. “The real preventive service a dental hygienist can perform is to recognize early signs of periodontal involvement so that treatment can be initiated to arrest the disease and prevent more severe involvement…The difficult part is to watch carefully for incipient, often isolated indications of early periodontal disease.” Ester Wilkins 6th Edition, Clinical Practice of the Dental Hygienist

4. Periodontal disease is episodic in nature and site specific. • Identifying small, incipient changes is our goal. • Hygienists need to have assistance to be effective.

5. Why??? • Patient is brought into their treatment. • Takes one third the amount of time. • Keeps the infection control chain linked. • Creates dialogue to help facilitate communication with patient

6. Effective Periodontal Charting In 5-7 Minutes • Five recordings necessary to develop treatment plan. • Pocket depths • Bleeding • Recession • Furcations • Mobility

11. Class I Furcation Fig. III-10

12. Class II Furcation Fig. III-11

13. Class III Furcation Fig. III-12

14. Together Everyone Accomplishes More

15. Hygiene Appointment Menu • Prophy • Therapeutic Removal of Hard & Soft Deposits • Initial therapy • Root Debridement/Detoxification therapy • Definitive therapy • Tissue evaluation • Laser therapy • Supportive periodontal treatment • Full Mouth Debridement • Child prophy and fluroide

16. Prophy • CDT 2016 Definition: Removal of plaque, calculus and stain from the tooth structures of permanent and transitional dentition. It is intended to remove irritating factors. • Workbook Definition: “this is a light supra and sub calculus removal and polish in the presence of a healthy mouth. Emphasis on instrumentation to remove coronal plaque, calculus, and stain. Evaluate personalized oral hygiene care.” Never used to treat periodontal disease

17. Therapeutic Removal of Hard & Soft Deposits • Workbook Definition: Scaling in presence of moderate or severe inflammation- full mouth • Used to treat gingivitis • Followed up with a prophy

18. Initial Therapy • Workbook Definition: You have two choices for this treatment depending on your patient: • Supra-gingival calculus removal, subgingival plaque removal and cosmetic polish. Or: • Scale and polish only the healthy teeth • Used as a transitional appointment for existing patients

19. Root Debridement Therapy • Workbook Definition: Periodontal scaling, root debridement and detoxifying of the roots using anesthesia, ultrasonics, laser if available, and antimicrobial irrigation. Customize individual plaque control program. • 1993 standard of care in the treatment of periodontal disease changed from “root planning” to “root debridement” • Root planning verses root debridement

20. Root Debridement Therapy

21. Definitive Therapy • Workbook Definition: Re-probing, light scale and polish or possible re-root debridement in an isolated area. Possible irrigation. Evaluating periodontal status and setting up on maintenance interval. • This is the most important appointment in the entire series of periodontal appointments. • Done 4 to 6 weeks after the last Root Debridement Therapy

22. Supportive Periodontal Treatment • CDT 2016 Definition: This procedure is instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planning where indicated, and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatmentprocedures must be considered. • Scheduled 8 to 12 weeks after the definitive therapy appointment. May be a shorter interval if the patient warrants a shorter interval. • Workbook Definition: To be used for patients who have completed periodontal therapy. Complete probing, periodontal scale, fine scale, subgingival plaque removal, and polish with possible isolated root debridement with anesthesia. (Laser practices will also incorporate lasers)

23. Supportive Periodontal Treatment • Periodic maintenance treatment following periodontal therapy is not synonymous with a prophylaxis. • Procedures: • Complete periodontal probing – General fine scale • Periodontal scale – Removal of subgingival plaque • Treatment of 3-4 isolated sites with root debridement incorporating anesthesia if necessary. (Laser practices will treat 2-3 isolated sites and incorporate the utilization of the laser) • Polish – Antimicrobial Irrigation – Desensitizing agent

24. Tissue Evaluation • Workbook Definition: Re-probing and evaluation of need for further treatment. • This is a 20 minute appointment • No instrumentation besides periodontal charting • Used predominately for gingivitis patients

25. Full Mouth Debridement • Workbook Definition: General scale to enable periodontal evaluation • The old “duck and cover” • Key Components of this appointment: • Remove gross calculus with ultrasonic • Educate the patient of the need to return to have a full periodontal evaluation now that you can get the probe subgingivally

26. Child Prophy and Fluoride • Workbook Definition: Light calculus and stain removal with polish/fluoride • When do you charge for an adult prophy? • How much time do you allot for a pedo prophy?

27. Case Typing • Unified philosophy of treatment specific to your office • Facilitates quick treatment planning • Communication between hygienists • Easy scheduling and financial presentations • Subjective Information • Objective Information • Inflammation is Key

29. Root Causes of Disease

31. …anything that elevates the inflammatory response may also speed the formation of amyloid plaques (cell-killing plaques that form in our brains). Steven Feske, M.D. Harvard Medical School Newsweek: October 3, 2005 • “In recent years, increasing evidence has supported the concept that the relationship between systemic and oral health is bi-directional. Much research has documented the association between periodontitis and its effects on preterm delivery and low birth weight newborns. Studies have also indicated that periodontal disease can increase the risk for cardiovascular disease, respiratory diseases, osteoporosis, and accelerate the progression of diabetes. The general mechanism behind the systemic effects of periodontitis is thought to involve, in part, a systemic inflammatory response through blood-borne oral lipopolysaccharides and oral bacteria.”Ray C. Williams, DMD Chair, Department of Periodontology University of North Carolina School of Dentistry January, 2005

32. It is evident that we can no longer view gingivitis simply as a precursor of periodontitis, but we should treat it as oral inflammation that needs to be controlled and eliminated for the overall well being of the individual. Ray C. Williams, DMD Chair, Department of Periodontology University of North Carolina School of Dentistry January, 2005 • “This is the most direct evidence yet that gum disease may lead to stroke or cardiovascular disease,” said Dr. Moise Desvarieux at Columbia University Medical Center, who led the study. “And because gum infections are preventable and treatable, taking care of your oral health could very well have a significant impact on your cardiovascular health.” AHA Circulation Magazine • There is growing evidence that chronic low-grade inflammation contributes to the development of many diseases, including Alzheimer's… Dr. Andrew Weil November 16, 2005

33. 50% of your success with periodontal therapy is patient compliance!!

34. Current Case Types:

35. Our Case Types:

36. Healthy: • Gingival tissue pink, firm stippled with minimal sulcus depth. • Treatment Plan: • Prophy • 3 or 6 month continuing care

37. Case Type I – Mild Gingivitis: • Generalized bleeding points with light deposits. Isn’t really a healthy mouth, but doesn’t warrant a series of appointments.

38. Case Type I – Mild Gingivitis: Treatment Plan: • Prophy – 60 minutes Followed up with either a: • Tissue Evaluation – 20 minutes Or: • 3 month continuing care

39. Case Type I – Moderate Gingivitis: • Clinical signs will either be red, inflamed, bulbous, rounded or blunted papilla that bleed easily, or firm, hard tissue with loss of stippling.

40. Case Type I – Moderate Gingivitis: Treatment Plan: • Therapeutic Removal of Hard and Soft Deposits • Fine Scale/polish • 3 month continuing care

41. Case Type II – Borderline Periodontitis • Clinical healthy with one to three isolated 4mm bleeding pockets. Treatment Plan: • Prophy • 60 minute Root Debridement/Detoxification • 12 week Supportive periodontal treatment

42. Case Type II – Beginning Periodontitis • Clinically you will see 3-4 mm recordings with the 4 mm typically around the molars

45. Case Type II – Beginning PeriodontitisTreatment Plan:

46. Case Type II – Early Periodontitis • Clinically 3 to 4mm pockets but the 4mm pockets are more profuse and confined to the molars still but creeping into the bicuspids. You may have an isolated 5mm pocket at this level.

49. Case Type II – Early PeriodontitisTreatment Plan:

50. Case Type III – Moderate Periodontitis • Clinically there will be generally 4 to 5mm readings. There could be an isolated 6mm pocket, too.